MEDICAL POLICY 7.01.508
Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery
Effective Date: March 1, 2018
Last Revised: Feb. 13, 2018
Replaces: N/A
RELATED MEDICAL POLICIES:
10.01.514 Cosmetic and Reconstructive Services
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POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING
RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY
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Introduction
There are usually two distinct reasons for eyelid surgery. The first is to change how a person
looks. Surgery that only changes how a person looks is cosmetic surgery; the plan does not
cover cosmetic surgery. The second reason for eyelid surgery is to fix a problem that causes
medical issues or interferes with the ability to see. This policy discusses when eyelid surgery is
covered.
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
Policy Coverage Criteria
Procedure Medical Necessity Blepharoplasty (15822,
15823)
Unilateral or bilateral blepharoplasty is considered medically
necessary to relieve obstruction of central vision when ALL of
the following criteria are met:
Documented complaints of interference with vision or visual
field-related activities causing significant functional impairment
https://www.premera.com/medicalpolicies/10.01.514.pdf
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Procedure Medical Necessity such as difficulty reading or driving due to upper eyelid skin
drooping or resting or pushing down on the eyelashes
AND
There is excess skin overhanging the upper eyelid margin (edge
of the eyelid) and resting on the eyelashes. This is confirmed by
photographs from the front and side(s ) with the camera at eye
level and the individual looking straight ahead
AND
Documentation of visual field testing with the eyelid skin
untaped shows a superior or peripheral visual field of 20
degrees that is corrected to normal visual field limits when the
excess upper eyelid skin is taped
Blepharoptosis Repair
(67901-67909)
Blepharoptosis repair is considered medically necessary to
relieve obstruction of central vision when ALL of the following
criteria are met:
Documented complaints of interference with vision or visual
field-related activities causing significant functional impairment
such as difficulty reading or driving due to eyelid position
AND
Photographs taken with the camera at eye level and the
individual looking straight ahead document the eyelid at or
below the upper edge of the pupil
AND
Documentation of visual field testing with the upper eyelid
margin untaped shows a superior or peripheral visual field of
20 degrees that is corrected to normal visual field limits when
the upper eyelid margin is taped
AND
The margin reflex distance (MRD) between the pupillary light
reflex at normal gaze and the upper eyelid skin edge is 2.0
mm
Brow Lift (67900) Brow lift (repair of brow ptosis due to laxity of the forehead
muscles) is considered medically necessary when ALL of the
following criteria are met:
Brow ptosis is causing a functional impairment of upper/outer
visual fields with documented complaints of interference with
vision or visual field related activities such as difficulty reading
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Procedure Medical Necessity due to upper brow drooping, looking through eyelashes, or
seeing the upper eyelid skin
AND
Photographs show the eyebrow below the supraorbital rim
AND
Documentation of visual field testing with the brow untaped
shows a superior or peripheral visual field of 20 degrees that
is corrected to normal visual field limits when the eyebrow is
taped
Children (9 years of age or
younger)
Blepharoptosis repair is considered medically necessary when
BOTH of the following criteria are met:
Individual is 9 years of age
AND
Intervention is intended to relieve obstruction of central vision
which is severe enough to produce occlusion amblyopia as
documented by the treating physician
Blepharoplasty,
blepharoptosis repair or
brow lift
Blepharoplasty, blepharoptosis repair or brow lift is considered
not medically necessary when performed to improve a
patients appearance in the absence of any significant signs or
symptoms of a functional visual impairment (see Related
Policies).
Lower eyelid
blepharoplasty
(CPT 15820, 15821)
Lower eyelid blepharoplasty to remove excess skin, fatty
tissue, or both, is considered not medically necessary in the
absence of the medical condition of ectropion, entropion, or
other functional visual impairment. Excess tissue under the eye
rarely obstructs vision.
Bilateral surgery When bilateral surgery is requested or performed and only one
eye meets the medical necessity criteria noted above, surgery
on the unaffected eye is considered not medically necessary in
the absence of signs or symptoms of a functional visual
impairment.
Documentation Requirements The patients medical records submitted for review for all conditions should document that
medical necessity criteria are met. The record should include the following:
Office visit notes that contain the relevant history and physical
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Documentation Requirements AND
Results of the visual field exam (when applicable)
AND
Clear color photographs from the front and side(s) with the camera at eye level and the
individual looking straight ahead (digital or film)
Additional documentation requirements for various conditions are detailed in the
table below.
CPT codes Procedure
Name Indication Additional documentation required
15820
15821
Lower eyelid
blepharoplasty
(See Coding section
for individual code
descriptions)
Lower eyelid
ectropion,
entropian, or
trichiasis
Blepharoplasty of the lower eyelid is generally
considered not medically necessary unless there is the
presence of corneal and/or conjunctival injury or
disease due to ectropian, entropian, Documentation
should include the corneal exposure specific
symptoms, duration, and severity
15822
15823
Blepharoplasty
(See Coding section
for individual code
descriptions)
Excess skin
(dermatochalasis,
blepharochalasis)
Photographs from the front and side(s) with the
camera at eye level and the individual looking straight
ahead document excess skin overhanging the upper
eyelid margin and resting on the eyelashes that are
consistent with the visual field loss on visual field test
results
67901
67902
67903
67904
67906
67908
67909
Blepharoptosis (repair
for laxity of the
muscles of the upper
eyelid)
(See Coding section for
individual code
description)
Eyelid droop
(Upper eyelid
ptosis,
blepharoptosis)
Photographs taken with the camera at eye level and
the individual looking straight ahead document the
eyelid at or below the upper edge of the pupil in
addition to the MRD and the automated visual field
test results
67900 Brow lift (repair of
brow ptosis)
Laxity of the
forehead muscles
(brow ptosis)
Photographs show the eyebrow below the supraorbital
rim in addition to the visual field test results
Coding
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Code Description
CPT 15820 Blepharoplasty, lower eyelid;
15821 With extensive herniated fat pad
15822 Blepharoplasty, upper eyelid
15823 With excessive skin weighting down lid
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg,
banked fascia)
67902 Frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
67903 (Tarso)levator resection or advancement, internal approach
67904 (Tarso)levator resection or advancement, external approach
67906 Superior rectus technique with fascial sling (includes obtaining fascia)
67908 Conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)
67909 Reduction of overcorrection of ptosis
Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
Related Information
Definition of Terms
When specific definitions are not present in a members plan, the following definition of terms
